Staff at the Multnomah County Health Department are leading a statewide initiative to rethink health care for refugees, people who have fled their home country to escape persecution. The move comes after the transition to Cover Oregon caused many new refugees in need of health care to suddenly have their insurance applications delayed or mistakenly denied.

The confusion over insurance processing spurred a team of refugee case workers and health experts called the Refugee Health Advisory Group to call for sweeping change to a system that has welcomed more than 60,000 refugees since 1975.

Their goal: to provide better access and better care for newly arrived families.

Many refugees land in the emergency room rather than seeking out their primary care doctor. And there aren’t enough trained mental health providers to meet their unique needs. High rent in the Portland-metro area is also pushing new arrivals to housing in suburban neighborhoods where clinics are unfamiliar with refugee health. And health and social service providers aren’t talking about how to plug refugees into other social services that support physical and mental health.

The Refugee Health Advisory Group has come up with a game plan for change. It includes redesigning the initial health screening process, streamlining health insurance applications, reaching out to providers in cities that might see an increase in refugee residents and building a network with social services providers who are or should be providing services to refugees.

“They wanted us to do right by our refugees; they wanted us to be a welcoming place,” said Amy Sullivan, the manager of Multnomah County Communicable Disease Services, who was among those spearheading the group. “I love working in a place where this stuff is important.”

When refugees resettle in the United States, they’re provided eight months of public assistance, including food stamps and rent vouchers. Those benefits, including medical coverage, begin they day they arrive.

That includes completing a mandatory health screening for immunizations and tests for infectious disease at Mid County Health Center.

Last year, health department staff at Mid County screened more than 1,000 new refugees from 40 countries, ranging from a single refugee from Malta to more than 300 refugees from Iraq.

When the Affordable Care Act went into effect, it meant many refugees could continue receiving health insurance after their other benefits expired.

For years, new arrivals could sign up for food stamps, housing vouchers and health insurance cards during a single visit to the state Department of Human Services (DHS). That changed when the Oregon Health Authority broke away from DHS.

Under health reform, caseworkers had to send refugees’ applications to Cover Oregon. In following months, many of those applications were delayed, misplaced or erroneously denied.

Without a physical insurance card in their hands, refugees found they could not receive care from their assigned providers. Frustrated refugee care providers came together to write a letter of concern to the Oregon Health Authority last year detailing the problems: one woman with epilepsy suffered seizures and was denied treatment; another was sent to an emergency room after being refused essential medication to treat a renal condition, and a third was denied safe housing in spite of severe schizophrenia.

Compounding the confusion was a delay in federal processing of new Social Security numbers for refugees. That led the state to cancel coverage for some refugees, many of whom couldn’t decipher the English cancelation letters they received in the mail.

In other cases, providers agreed to see refugee patients only to charge the indigent immigrants full price for the visits. One refugee caseworker said she spent so many hours fighting with providers and collection agencies over unpaid medical bills that she had become an expert in medical billing.

“For mental health service providers, their ability to serve newly arrived refugees is at a stand-still,” the group wrote in their letter to the Oregon Health Authority. “These clients are presenting with acute mental health distress, yet providers cannot initiate services without verification of health insurance coverage. Your immediate attention to this matter is greatly appreciated.”

The Refugee Health Advisory Group, made up of medical experts, county and state officials and caseworkers, teamed up with the Oregon Health Authority to find a solution: flag applications for new refugees and send them to a single person who can expedite the application process.

But those conversations led to discussion of how to solve more systemic problems:

Even when insured, many refugees didn’t visit a primary care doctor. Instead, when they suffered minor illness or when a preventative illness became a crisis, they went to the emergency room.

Many refugee clients have been traumatized by war and forced relocation. Yet Oregon doesn’t have enough mental health providers with the cultural awareness and language skills to address their needs.

Housing costs in the Portland area have also driven displaced persons away from the central city to more affordable, but suburban neighborhoods where fewer health providers are familiar with the needs of refugees.

And everyone serving refugees was so busy, that the system lacked capacity to make real change.

“We rechartered the group to focus on what is happening to the refugee health care system, to build a system that gets people screened and gets them the services they need,” Communicable Disease Services manager Sullivan said. “That group said, ‘we need more support.’”

Toc Soneoulay-Gillespie​, director of resettlement at Catholic Charities, said agencies like hers are struggling to resettle new arrivals in the Portland area, where services are concentrated.

“We can’t afford that anymore,” she said. “We’re supposed to resettle within a 100-mile radius. Other places are vibrant and ready.”

Advisory group member Sasha Verbillis-Kolp with the refugee resettlement agency Lutheran Community Services NW, says better access to mental health services could be the most significant opportunity to come from the Affordable Care Act.

“These folks have 10 times the rate of PTSD compared to people who aren’t refugees,” said Verbillis-Kolp, who coordinates a program that provides mental health screening and counseling for incoming refugees. “We need to look at health disparities not just as a city, and not just as a county, but as a state. Someone has to look closely and advocate for their needs.”

Oregon, like other states, has an official Refugee Coordinator, but the DHS manager’s primary job is overseeing a program that helps 20,000 low-income working families pay for childcare. She has two staff members who concentrate on refugees.

Oregon also has a Refugee Health Coordinator: but that person, Tasha Wheatt-Delancy, is also the senior manager of the Mid County Health Center, the largest public primary care clinic in the state.

Wheatt-Delancy came into her job in September and made improving refugee health a top priority. She is tackling the overhaul with help from her team at Mid County and from Charlene McGee, the new deputy refugee health coordinator.

They’re marking this focused care within the Mid County clinic with a new name: the Rose City Refugee Clinic.

“It’s going to be totally different; the way we welcome people into what is essentially an international health clinic,” Wheatt-Delancy said. “When you walk in the door you walk into a thriving, changing clinic inspired by the different languages and cultural backgrounds of the clients and our own team. We are inspired everyday by the resilience of the patients that we serve."